Author: Qualify Health

Columbus SC— September 15^th, 2022. Monique Lappas, Founder and Chief Executive Officer, , of Qualify Health presented at the Association of South Carolina Oncology Managers (ASCOM).

The conference was held at Columbia  Metropolitan Convention Center , Columbia SC

The event was attended by over 40 representatives from some of South Carolina’s leading Oncology Providers, as well as other industry executives.

The topic of Ms. Lappas’ presentation was “Growing Your Revenues and Bringing Your Patients to Tears (OF JOY!)”, in which she presented case studies of the impact that Qualify Health’s software and service solution can drive financial advocacy, increased advocacy dollars, improved patient satisfaction and the company’s AI-Driven Prior Authorization platform to solve the increasing burden of Prior Authorizations.

The association of South Carolina Oncology Managers is a non-profit professional organization that provides access for oncology practices to quality leadership development through continuing education, networking, and business improvement opportunities

Qualify Health is one of the country’s leading technology and service providers for healthcare-based financial advocacy solutions and AI-driven prior authorization Solutions.

What is a Copay Assistance Program?

As healthcare costs continue to rise, patients are looking for ways to save on medication costs. Providers want to make sure they get compensated for any patient out-of-pocket expenses due to them. When insurance is not enough to cover the total cost, patients struggling to afford expensive drugs turn to Manufacturer Copay Assistance Programs or Copay Cards to help with the out-of-pocket expenses. Pharmaceutical companies typically offer these programs. The program’s purpose is to help people with commercial or private insurance cover their deductibles, copays, and co-insurance directly related to the cost of their prescription drugs.

How do Copay Assistance Programs work?

Copay Cards reduce the total out-of-pocket expenses for the patient. Once approved for the program, the patient’s insurance is billed first and covers some of the drug’s cost, then the manufacturer covers most, if not all, of the remaining out-of-pocket expense.

How to apply for a Copay Assistance Program?

If your physician practice or specialty pharmacy does not partner with someone like Q Consulting Services, then the patient can access Copay Card programs through the manufacturer’s website. To sign up for the program, they will register online, or call the program to enroll. Once you are enrolled, you are provided with your member information and possibly a credit card to use at your pharmacy or provider’s office– this varies among programs.

If your practice/specialty pharmacy partners with a company like Q Consulting Support Services (QCSS) , we will sign up the patient and maintain their membership, and give you and the patient any information they need.

What are the requirements or restrictions?

For most Copay Card Programs, there are two main requirements:

1. The patient must have commercial or private insurance.

2. You cannot have government health insurance, such as Medicare, Medicare Advantage Plans, or Medicaid.

How to receive reimbursement for out-of-pocket expenses?

There are three possible scenarios:

1. The patient is filling their prescription (e.g., Humira) at the provider or hospital-owned specialty pharmacy. The pharmacist will process the patient’s insurance as the primary payer and the copay card as the secondary payer. The Copay Card Program may cover the out-of-pocket expense in its entirety, or the patient may be responsible for a tiny portion – generally around $5.

2. The patient is receiving an infusion (e.g., Herceptin, Stelara) at an out-patient facility. The facility will bill the primary insurance for the drug. Once the insurance company pays its portion, the explanation of benefits (EOB) will indicate the patient’s out-of-pocket expense. The patient is then responsible for submitting the EOB to the program. When the claim is approved, the program will mail a check or upload the reimbursement to a credit card.

3. QCSS can manage the entire reimbursement process, from electronically receiving the EOB as soon as the billing occurs, to and ensuring that the charge is loaded on the copay card and making sure the physician office is paid by either managing check requisitions or running the copay cards through your POS.

How do patients and healthcare professionals benefit from Copay Assistance Programs?

Copay Assistance Programs lessen the patient’s financial burden, making it easier for them to obtain their prescription and ensure that the appropriate treatment is attainable.

Q Consulting Support Services specializes in the management of Copay Card programs. Our dedicated staff partners with clients ranging from small oncology practices to the country’s largest healthcare systems. Our Support Service team enrolls the patient into the Copay Card Program, monitors and submits EOBs with patient out-of-pocket expenses, and follows-up on any denials to ensure payment is received promptly. Ultimately, increasing patient satisfaction and reducing the financial burden on the provider’s office or facility by guaranteeing patient out-of-pocket expenses are obtained, which reduces bad debt and increases revenue.

How to find Foundation Assistance for patients

Foundation Assistance for Chronic or Life-Altering Diseases

Foundations offer financial assistance to those suffering from Chronic or Life-Altering Diseases when insurance is not enough to cover the treatment. Foundations help fill the gaps by assisting patients with their out-of-pocket expenses.

What is Foundation Assistance, and Who offers it?

Non-profit organizations like The Leukemia & Lymphoma Society, Healthwell Foundation, and the PAN Foundation, to list a few, provide financial assistance to patients in need. These foundations offer specific disease funds and award assistance to patients via grants. The grants awarded may cover copays, deductibles, insurance premiums, co-insurance and may help with travel or household expenses.

Who is eligible for Foundation Assistance?

Available funding is disease-specific – you must be diagnosed with the disease, be actively receiving treatment in the United States, have insurance covering the medication and therapy, and fall within a certain percentage of the Federal Poverty Level Guidelines (FPL). Unlike Manufacturer Copay Assistance Programs, Foundations allow applicants to have Federally Funded insurance like Medicare and Medicare Advantage plans.

If your practice/specialty pharmacy partners with a company like Q Consulting Support Services (QCSS), we will enroll all qualified patients, maintain their enrolment, and manage the entire billing and collections process.

How to apply for Foundation Assistance?

Disease fund availability is dependent upon whether there is sufficient funding available. Funds open and close daily, making the application process more difficult than other financial assistance programs. If a fund is accepting applications, you should apply immediately.

Step 1: Gather Information for the application.

• Demographics (including Social Security Number)
• Diagnosis
• Estimated household financial income
• Insurance information
• Pharmacy contact information
• Treating physician contact information

Step 2:

• Apply online or over the phone.

Alternatively, QCSS can manage the entire process, from enrolling patients as soon as a fund opens and helping them manage their financial paperwork to ensure all claims are submitted and reimbursed promptly.

How much financial assistance can I receive, and how is it paid out?

The award levels range from $100 to over $10,000 per applicant, depending on the fund. The full grant amount is allocated over one year and reimburses for services and treatments rendered during this period via the fund’s reimbursement process.

Keeping your grant active

Foundations want to ensure that grants are being used by those actively receiving treatment and in need of financial assistance. Many foundations require initial reimbursement requests to be submitted within a specific time frame and do not allow extended periods of inactivity, or the awardee could lose the grant completely. The time frames vary between 90-120 days.

Q Consulting Support Services specializes in managing Foundation Grants for our clients. We actively monitor Foundation sites to apply for our patients as soon as a fund opens up. Additionally, we ensure that all reimbursement requests are submitted timely so that our patients do not lose their funding and may continue to pay their providers for services rendered.

How helping patients find financial advocacy improves patient satisfaction and reduces bad debt

How Patient Financial Advocacy Improves Patient Satisfaction and Reduces Bad Debt

Patient Financial Experience

The patient financial experience within the U.S. Healthcare System is unique due to the variety and complexity of the different payer-systems. A patient’s expectation of their medical bill being as straightforward as the treatment should not be unrealistic. However, it is not of this time. In combination with the complex nature of medical bills, the patient’s out-of-pocket responsibility has increased due to high deductible and high-cost sharing insurance plans.

A TransUnion Healthcare analysis revealed that patients are, on average, experiencing at least a 10% increase in average annual out-of-pocket costs, and the average burden on each patient is approximately $2,000 – an unaffordable hurdle for most patients that is leading to millions of dollars of bad medical debt for the average healthcare system.

Given the constant media attention about the burden of healthcare costs, patients are increasingly expecting their practitioner to either help them with patient financial advocacy or absorb some of the patient’s financial burden due to financial hardship. Therefore, it is in the best interest of all parties for the physician/hospital/pharmacy to provide financial advocacy services in tandem with clinical services to improve revenue recovery and patient loyalty.

Patient satisfaction and patient experience are inextricably linked. As patient out-of-pocket responsibility continues climb, the medical practices that take proactive measures to help meet the patient’s financial needs and improve the patient experience will be the practices to prosper.

Any practice that has attempted to provide in-house patient financial advocacy soon comes to realize the administrative burden that it puts on existing staff, and often are required to hire additional FTE’s to manage these programs on behalf of their patients. This is where Q Consulting Support Services steps in.

Q Consulting Support Services specializes in providing Financial Advocacy to help patients with the out-of-pocket expenses associated with treatment. Our dedicated staff partners with clients ranging from small oncology practices to the country’s largest healthcare systems. Our Support Service team applies for funding on the qualifying patient’s behalf through grants and financial assistance programs. After funding approval, we monitor and submit EOBs with patient out-of-pocket expenses, and follows-up on any denials to ensure payment is received promptly. Ultimately, increasing patient satisfaction and reducing the financial burden on the provider’s office or facility by guaranteeing patient out-of-pocket expenses are obtained, which reduces bad debt and increases revenue.

How QCSS was able to secure over $16,000 in financial advocacy for this patient

Patient Overview: Mr. V.

Like many newly diagnosed cancer patients, Mr. V’s life took a frightening detour when he was diagnosed with Locally Advanced Pancreatic Cancer at the age of 56. When he began treatment, he only had Medicare Part A benefits and had recently lost his job due to the COVID-19 Pandemic. His household income, which included his unemployment and his wife’s income, totaled about $2,000 a month, putting him at around 150% of the Federal Poverty Level.

Medication & Cost

The oncologist prescribed our patient Abraxane, Gemzar, and Creon to treat his Pancreatic Cancer and after consultation with Q Consulting Services and the hospital, he learned that his medications were going to cost him more than $12,000 a month, and did not have appropriate insurance coverage to help with the expense. For this couple on a fixed income, the cost would be impossible to cover. It was at this point that the hospital’s oncology business asked Q Consulting Support Services (QCSS) to step in, with the request that we help the patient avoid incurring an untenable amount of debt and assist the hospital in being reimbursed, where possible, for Mr. V’s treatment.

Outcome

The patient worked on getting additional insurance coverage and signed up for Medicare Part B., while QCSS simultaneously secured free drugs for Abraxane and Creon.

QCSS understands that a patient’s focus should be on their recovery while the physicians, nurse and hospital’s focus should be on patient care. With this in mind, we fully managed the entire enrollment, billing, and ordering process throughout Mr. V’s treatment, alleviating our client, The Greater Baltimore Medical Center, and the patient from this added burden. The patient received his medication for free, and our client avoided a potential loss of over $12,000 a month.

Once the patient secured his Medicare Part B insurance, QCSS then obtained a fund through the PAN Foundation to cover his 20% out-of-pocket expenses. Our client would be able to bill and receive reimbursement through Medicare, while our patient’s out-of-pocket costs were also fully covered.

This patient required more assistance due to the circumstances of his unemployment. QCSS provided further assistance by finding alternative funding options like The Good Days Emergency Relief Fund to help this patient with household expenses and utility payments.

Over three months, we were able to secure over $16,000 in financial advocacy for this patient. This patient was so appreciative of our services and the financial assistance we were able to provide through one of the most challenging times of his life. He focused on his health instead of stressing over the burden of expensive healthcare treatment

How QCSS was able to help Michael with $42,000 of medication costs

Patient Overview: Michael

Michael is a 50-year-old father of three with a combined family income of over $175,000 per year, who, in October 2020, was unexpectedly diagnosed with Chronic Myeloid Leukemia (CML). Michael had always been a healthy person and was not on any chronic-care medications, so while he had a great insurance plan, he had opted out of prescription coverage.

Upon learning of his diagnosis, Michael immediately enrolled in the insurance plan’s prescription coverage, but it would not become effective until January 2021

Medication & Cost

To Treat Michael’s CML, his Oncologist prescribed a Sprycel, an oral chemotherapy medication with a retail price of $14,130 for a 30-day supply, or, for Michael, a 3-month out-of-pocket cost of $42,390.

Michael was faced with either finding a way to afford his medication, choosing an alternate but less optimal medication, or delay treatment until his prescription plan began. The oncologist felt strongly that the patient begin the medication without delay but also understood the financial burden that it placed on Michael, so he contacted Q Consulting Support Services (QCSS) to help the father of three figure out what options might be available for affording this life-saving treatment.

The drug manufacturer offered a 30-day free trial, so QCSS immediately enrolled the patient into this option.

Challenges to Patient Assistance Program

The biggest hurdle in helping Michael with securing the next two months of medication at a price that he could afford was the combined family income of $175,000 a year. This level was above 500% of the Federal Poverty Level and pushed him outside of the eligibility level for the drug manufacturer’s patient assistance program (PAP).

October’s prescription was taken care of by the 30-day free trial, we QCSS had 30 days to figure out how we would secure November and December’s medication. After speaking with the territory pharmaceutical representative and stating the patient’s case, we learned that the only hope for assistance was through the manufacturer’s patient assistance program, despite his ineligibility

The Final Appeal

Even though the patient did not meet the income qualifications for assistance, we moved ahead with the application. QCSS’s Patient Service Advocate spent hours on the phone with the manufacturer’s PAP explaining the patient’s unfortunate circumstances. The foundation denied the patient’s application and notified us that the only remain would be to file an appeal on the patient’s behalf.

QCSS was transparent with both the patient and the physician throughout the entire process. There was no guarantee that we would be successful, but would do our best and go above and beyond in ensuring that all information about the patient and the financial hardship that would result in treatment was submitted. However, until the final appeal was heard, there was uncertainty if Michael would be able to continue his treatment and we wanted to ensure that both physician and patient were emotionally prepared for another denial.

A Successful Outcome

With this last-ditch option, many more hours on the phone, filling out applications, submitting financial documents, and making the patient’s case to the drug manufacturer, the free medication was approved!

How hospitals and oncology centers can reduce bad debt through Patient Assistance Programs, Copay Cards and Foundations

The ultimate goal of a hospital or healthcare organization is to provide exceptional patient care; however, making a profit is necessary to achieve that goal.

According to a survey from Sage Growth Partners, a healthcare research firm, more than a third of hospitals rack up at least $10 million in bad debt each year, and half do not expect to recover more than 10% of it from payors or patient out-of-pocket expenses.

Understanding Out-of-Pocket Expenses can be Complicated

Healthcare providers are more challenged than ever when providing quality care to an increasing number of patients facing unaffordable out-of-pocket costs due to high deductibles, being under-insured, or uninsured. With each of these financial hurdles, hospitals and medical practices face a tough decision:

1. Send the patient a constant stream of letters and notices informing them of their outstanding balance due

2. Write-off the payment as bad debt and carry it on their balance sheet with the expectation that payment is unlikely

Most patients’ bad debt accumulates because a patient cannot afford the balance after their insurance has covered its portion of the expense. Most medical insurance plans only cover part of the fee due to the provider, leaving the patient with out-of-pocket costs. These out-of-pocket costs include deductibles, coinsurance, and copayments.

Patients are often unaware of their out-of-pocket expense before their treatment, and in many cases, even if they are aware, they are unable to afford them. While it is ideal for a provider to collect all out-of-pocket expenses upfront, this is not always possible, especially for costly services like chemotherapy, GI infusions, and other expensive in-office injectables. The insurance carrier processes the medical claim first to calculate the patient’s responsibility and then reports it back to the provider on the explanation of benefits (EOB). It is then up to the provider to collect these payments by billing the patient.

Most organizations offer various options to make the payment process easier via patient portals and electronic payment options. However, these options are beneficial only if your patient can afford to pay. If the patient cannot afford their bill, they may qualify for a payment plan or financial assistance. Unfortunately, this extra step is not always enough, and the debt starts to mount.

Improving Cash Flow Management

Cash flow management is essential to all healthcare organizations’ viability, and their accounts receivable days are under constant measurement. Nearly all healthcare organizations bill insurance regularly to ensure ample cash flow and proactively send out a series of notices to patients to settle outstanding accounts. In these notices, the patient is instructed to submit payment within a given time frame. If payment is not received, the provider will send the patient to collections (likely lowering patient satisfaction scores). However, sending a patient to collections does not guarantee payment and usually just reduces the provider’s reimbursement because the collection agency imposes a fee for their services.

Using a billing and collection process as the only means to collect monies owed is inefficient and usually unsuccessful, particularly when patients cannot afford their bills. While it is essential to maximize collections, organizations must be careful not to take collection practices to an extreme. They risk alienating patients, receiving more patient complaints, and ultimately reducing collections.

There is a Better Way

There are many ways to avoid the ‘bad debt’ cycle that your practice might find itself in, particularly when helping patients cover their infusion and in-office drug costs. By taking advantage of many of the manufacturers, foundation, and non-profit support programs, it is likely that your patients will be able to find the help they need to cover their out-of-pocket costs.

Q Consulting Support Services – Patient Financial Advocacy

Q Consulting Support Services (QCSS) offers financial advocacy to patients through many financial assistance programs. We work closely with your clinical team to identify patients who are uninsured, underinsured, have high-out-of-pockets expenses, or high balances that qualify for assistance for their prescription drugs or infusion drugs. Below is a list of the most frequently used financial assistance routes; however, we are not limited to these options. QCSS has a comprehensive database of financial assistance programs we use to ensure we exhaust all avenues for our patients and clients.

Financial Advocacy Options:

Manufacturer Copay Card Assistance:

Drug Manufactures offer Copay Card assistance programs. The program’s purpose is to help people with commercial or private insurance cover their deductibles, copays, and coinsurance directly related to their prescription drugs’ cost.

Patient Assistance Programs:

These programs, frequently called PAPs, are designed to help those in need obtain their medications at no cost or very low cost. Many, but not all, pharmaceutical companies have PAPs.

Foundation Assistance – Copay and Premium:

Foundations offer financial assistance to those suffering from Chronic or Life-Altering Diseases when insurance is not enough to cover the treatment. Foundations help fill the gaps by assisting patients with their out-of-pocket expenses or covering costly insurance premiums.

Q Consulting offers a team of professionals that will find, source, and manage the much-needed financial assistance available to many of your patients. QCSS has a tremendous track record in reducing bad debt for providers through our financial advocacy program. One of our current clients reduced their bad debt by 70 percent within six months. Through this period, QCSS collected over $300 thousand in copay card assistance, $600 thousand in PAP (Free Drug/Replacement) assistance, and $200 thousand through other funding sources – adding up to over $1 million in financial advocacy found for this client.

If given the opportunity, QCSS will successfully help your organization recover patient balances through our financial advocacy program, ultimately reducing bad debt, increasing profits, and boosting available cash flow. We take the burden off your team so they can focus on what they do best-providing exceptional care to your patients.

Hospitals can improve infusion center profitability by focusing on one area – the Insurance Verification Process and Prior Authorizations.

Numerous factors have contributed to the shift of outpatient infusion services from the private practice setting to the hospital outpatient setting. As this trend continues, hospitals must focus on one area that can help guarantee the center’s profitability: verifying patient insurance benefits.

Many outpatient hospital-based infusion centers struggle to be profitable due to a lack of resources required to verify patient insurance. The verification process consists of three components: Verification, Eligibility, and Prior-Authorization.

Let us break down each component:

Step 1: Insurance Verification:

Does the patient have insurance, and are the infusion services covered under their plan? The intake department completes the verification process upon admission by calling the insurance carrier (which can be time-consuming), through the EMR system – if offered, or through another platform like Availity.

Verification of benefits ensures the patient has coverage for the specified treatment plan and indicates if prior authorization is required.

Step 2: Eligibility

During the insurance verification process, you must also determine the plan’s eligibility period. Is the patient eligible for services during the time that you will be performing the infusion? Completing this step before EACH infusion ensures there is no lapse in coverage or that the policy is still active and has not been terminated (which can happen for various reasons).

Step 3: Prior-Authorization (PA):

Once you have determined that the patient’s insurance plan requires prior authorization, you must ensure the patient meets the plan requirements. This process generally requires sharing information from the patient’s medical record. Providing the medical record will establish medical necessity and explain why the physician prescribed one drug over another more affordable option– possibly due to previous product failure or patient allergy. The health insurance company will review the physician’s recommendation and either approve or deny the authorization request.

It is imperative to note that medical care will need to be approved by the insurance carrier before treatment is received. The medical claim will be denied without prior authorization.

The prior-authorization process can be burdensome. According to the American Medical Association (AMA), 9 in 10 physicians find that prior authorizations have a negative impact on patient outcomes and believe the burden associated with PAs has increased over the past five years.

Revenue Cycle Management (RCM) and Prior Authorizations

Prior authorizations are a pain point for providers yet are crucial to the revenue cycle and clinical care operations. The RCM process ensures that patients can access the necessary care and providers get paid for delivering services.

Patient Revenue is tracked and managed through the RCM process, starting at the initial encounter through to the final payment. The cycle encompasses all administrative and clinical functions contributing to capture, management, and collections from the patient and their insurance provider.

Revenue Cycle Management is critical to operating a thriving infusion center; It requires the strategic management of Insurance Verification, Eligibility, and Prior Authorization. With the rising cost of drugs, shrinking margins, and overall changes in the drug and healthcare industry, providers need to be sure they have a knowledgeable team who can sustain a healthy revenue cycle.

Everyone plays a vital role in ensuring correct reimbursement for these high-cost drugs – but most organizations or infusion centers do not have adequate staffing or additional resources for such an undertaking.

Financial Advocacy – Supporting a Healthy Revenue Cycle

Q Consulting Support Services (QCSS) provides a team of financial advocates that can help the infusion center maintain a revenue cycle that maximizes revenue collection while keeping the patient at the center of each transaction.

QCSS is a full-service insurance verification, prior authorization, financial counseling, financial advocacy, and specialty pharmacy management program.

Most importantly, we begin by verifying insurance benefits so both the provider and the patient know the out-of-pocket expenses related to the planned treatment. Once our financial advocacy team identifies patients that are under-insured or have high out-of-pocket costs, we determine which supplemental coverage sources are available to help manage their healthcare costs and ensure the provider receives payment for services delivered. We continue to oversee the entire reimbursement process, whether for a Manufacturer Copay Card, Foundation Assistance, or Free Drug through a Patient Assistance Program.

QCSS will also manage the Prior Authorization Process to guarantee that patients get access to the medications they need on time – alleviating the clinical team’s administrative burden and allowing them to focus on patient care.

The revenue cycle in healthcare is complex, requiring continuous process improvements to keep pace with the ever-changing industry. QCSS would welcome the opportunity to partner with your infusion center to improve your revenue cycle and assist your staff and patients with all their financial assistance needs.